Facts you should know when submitting a complaint…

If a “professional” has done you wrong, do not hesitate to take action.
CLICK HERE TO GO TO THE PA LICENSING BOARD WEB SITE

CLICK HERE TO PRINT THE COMPLAINT FORM

CLICK HERE TO SUBMIT YOUR COMPLAINT ONLINE

The Pennsylvania Department of State receives complaints concerning the Bureau of Commissions, Elections and Legislation, which issues notary commissions; the State Athletic Commission, which registers athletic agents; the Bureau of Charitable Organizations; and licensees and registrants of the following 29 professional and occupational licensing boards & commissions regulated by the Department’s Bureau of Professional and Occupational Affairs:

Accountancy
Architects Licensure Board
Auctioneer Examiners
Barber Examiners
Certified Real Estate Appraisers
Chiropractic
Cosmetology
Crane Operators
Dentistry
Registration Board for Professional Engineers, Land Surveyors and
      Geologists
Funeral Directors
Landscape Architects
Massage Therapy
Medicine
Nursing
Examiners of Nursing Home Administrators
Occupational Therapy Education and Licensure
Optometry
Osteopathic Medicine
Pharmacy
Physical Therapy
Podiatry
Psychology
Real Estate Commission
Social Workers, Marriage and Family Therapists and Professional
      Counselors
Examiners in Speech – Language and Hearing
Vehicle Manufacturers, Dealers and Salespersons
Veterinary Medicine 
The Navigation Commission for the Delaware River and its Navigable Tributaries

If you believe the practice or the service provided by a licensee or registrant of the above-named boards or commissions to be unethical, immoral, below an acceptable standard of practice or out of the scope of the profession, you are urged to file a Statement of Complaint Form with the Department of State.
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How to avoid chiropractic fraud

How to avoid chiropractic fraud

Insurance Fraud and Abuse: A Very Serious Problem

Insurance Fraud and Abuse:A Very Serious Problem

by:  Stephen Barrett, M.D.

Fraud and abuse are widespread and very costly to America’s health-care system. Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit. An example would be billing for services that are not rendered. Abuse involves charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced. An example would be performing a laboratory test on large numbers of patients when only a few should have it. Abuse may be similar to fraud except that it is not possible to establish that the abusive acts were done with an intent to deceive the insurer.
Although no precise dollar amount can be determined, some authorities contend that insurance fraud constitutes a $100-billion-a-year problem. The United States Goverment Accountability Office (GAO) estimates that $1 out of every $7 spent on Medicare is lost to fraud and abuse and that in 1998 alone, Medicare lost nearly $12 billion to fraudulent or unnecessary claims [1].

Type of Fraud and Abuse

False claim schemes are the most common type of health insurance fraud. The goal in these schemes is to obtain undeserved payment for a claim or series of claims [2]. Such schemes include any of the following when done deliberately for financial gain:

  • Billing for services, procedures, and/or supplies that were not provided.
  • Misrepresentation of what was provided; when it was provided; the condition or diagnosis; the charges involved; and/or the identity of the provider recipient.
  • Providing unnecessary services or ordering unnecessary tests [3].

Many insurance policies cover a percentage of the physician’s “usual” fee. Some physicians charge insured patients more than uninsured ones but represent to the insurance companies that the higher fee is the usual one. This practice is illegal. It is also illegal to routinely excuse patients from copayments and deductibles. (A copayment is a fixed dollar amount paid whenever an insured person receives specified health-care services. A deductible is the amount that must be paid before the insurance company starts paying.) It is legal to waive a fee for people with a genuine financial hardship, but it is not legal to provide completely free care or discounts to all patients or to collect only from those who have insurance. Studies have shown that if patients are required to pay for even a small portion of their care they will be better consumers and select items or services because they are medically needed rather than because they are free. Routine waivers thus raise overall health costs. They are considered fraudulent because averaging them with the doctor’s full fees would make the “usual” fees lower than the amounts actually billed for.
Other illegal procedures include:

  • Charging for a service that was not performed.
  • Unbundling of claims: Billing separately for procedures that normally are covered by a single fee. An example would be a podiatrist who operates on three toes and submits claims for three separate operations.
  • Double billing: Charging more than once for the same service.
  • Upcoding: Charging for a more complex service than was performed. This usually involves billing for longer or more complex office visits (for example, charging for a comprehensive visit when the patient was seen only briefly), but it also can involve charging for a more complex procedure than was performed or for more expensive equipment than was delivered. Medicare documentation guidelines describe what the various levels of service should involve [4].
  • Miscoding: Using a code number that does not apply to the procedure.
  • Kickbacks: Receiving payment or other benefit for making a referral. Indirect kickbacks can involve overpayment for something of value. For example, a supplier whose business depends on physician referrals may pay excessive rent to physicians who own the premises and refer patients. Another example would be a mobile testing service that performs diagnostic tests in a doctor’s office. Kickbacks can distort medical decision-making, cause overutilization, increase costs, and result in unfair competition by freezing out competitors who are unwilling to pay kickbacks. They can also adversely affect the quality of patient care by encouraging physicians to order services or recommend supplies based on profit rather than the patients’ best medical interests. In 2000, the Office of the Inspector General issued a fraud alert warning against kickbacks disguised as rental payments [5].

Criminals sometimes obtain Medicare numbers for fraudulent billing by conducting a health survey, offering a free “health screening” test, paying beneficiaries for their number, obtaining beneficiary lists from nursing homes or boarding facilities, or offering “free” services, food, or supplies to beneficiaries.

Excessive or Inappropriate Testing

Many standard tests can be useful in some situations but not in others. The key question in judging whether a diagnostic test is necessary is whether the results will influence the management of the patient. Billing for inappropriate tests—both standard and nonstandard—appears to be much more common among chiropractors and joint chiropractic/medical practices than among other health-care providers. The commonly abused tests include:

  • Computerized inclinometry: Inclinometry is a procedure that measures joint flexibility. Inclinometer testing may be useful if precise range-of-motion measurements are needed for a disability evaluation, but routine or repeated measurements “to gauge a patient’s progress” are not appropriate [6].
  • Nerve conduction studies: These tests can provide valuable information about the status of nerve function in various degenerative diseases and in some cases of injury [7]. However, “personal injury mills” often use them inappropriately “to “follow the progress” of their patients.
  • Surface electromyography: This test, which measures the electrical activity of muscles, can be useful for analyzing certain types of performance in the workplace. However, some chiropractors claim that the test enables them to screen patients for “subluxations” and to follow their progress. This usage is invalid [6].
  • Thermography: Thermographic devices portray small temperature differences between sides of the body as images. Chiropractors who use thermography typically claim that it can detect nerve impingements or “nerve irritation” and is useful for monitoring the effect of chiropractic adjustments on subluxations. These uses are not appropriate [6].
  • Ultrasound screening: Diagnostic ultrasound procedures have many legitimate uses. However, ultrasonography is not appropriate for “diagnosing muscle spasm or inflammation” or for following the progress of patients treated for back pain [6].
  • Unnecessary x-rays: X-rays examinations can be important to look for conditions that require medical referral. However, it is not appropriate for chiropractors to routinely x-ray every patient to look for “subluxations” or to “measure the progress” of patients who undergo spinal manipulation [6].
  • Spinal videofluoroscopy: This procedure produces and records x-ray pictures of the spinal joints that show the extent to which joint motion is restricted. For practical purposes, however, simply physical examination procedures (such as asking the patient to bend) provide enough information to guide the patient’s treatment [6].

Many insurance administrators are concerned about chiropractic claims for “maintenance care” (periodic examination and “spinal adjustment” of symptom-free patients) , which is not a covered service. To detect such care, many companies automatically review claims for more than 12 visits. In 1999, the U.S. Inspector General recommended automatic review after no more than 12 visits for Medicare recipients [8]. Some chiropractors attempt to avoid review by issuing a new diagnosis after the 12th visit.

Personal Injury Mills

Many instances have been discovered in which corrupt attorneys and health-care providers (usually chiropractors or chiropractic/medical clinics) combine to bill insurance companies for nonexistent or minor injuries. The typical scam includes “cappers” or “runners” who are paid to recruit legitimate or fake auto accident victims or worker’s compensation claimants. Victims are commonly told they need multiple visits. The providers fabricate diagnoses and reports and commonly provide expensive but unnecessary services. The lawyers then initiate negotiations on settlements based upon these fraudulent or exaggerated medical claims. The claimants may be unwitting victims or knowing participants who receive payment for their involvement [9]. Mill activity can be suspected when claims are submitted for many unrelated individuals who receive similar treatment from a small number of providers.

Quackery-Related Miscoding

In processing claims, insurance companies rely mainly on diagnostic and procedural codes recorded on the claim forms. Their computers are programmed to detect services that are not covered. Most insurance policies exclude nonstandard or experimental methods. To help boost their income, many nonstandard practitioners misrepresent what they do. They may also misrepresent their diagnosis. For example:

  • Brief or intermediate-length visits may be coded as lengthy or comprehensive visits.
  • Patients receiving chelation therapy may be falsely diagnosed as suffering from lead poisoning; and the chelation may be billed as “infusion therapy” or simply an office visit [10].
  • The administration of quack cancer remedies may be billed as “chemotherapy.”
  • Live-cell analysis may be billed as one or more tests for vitamin deficiency.
  • Nonstandard allergy tests may be represented as standard ones.
  • Services not covered because they were performed outside of the United States may be billed as though they were performed within the United States.

Other Overbilling Schemes

In 2000, a Government Accounting Office (GAO) official told a Congressional committee how four other types of schemes are carried out:

  • In “rent-a-patient” schemes, organizations pay (“rent”) individuals to go to clinics for unnecessary diagnostic tests and cursory examinations. Licensed physicians sometimes participate in the rent-a-patient scheme. Insurers are billed for those services and often for other services or medical equipment never provided. In a variation of this scheme, perpetrators merely buy individual health care insurance identification numbers for cash.
  • In “pill mill” schemes, separate health care individuals and entities—usually including a pharmacy—collude to generate a flood of fraudulent claims that Medicaid pays. After a prescription is filled, the beneficiary sells the medication to pill buyers on the street who then sell the drugs back to the pharmacy.
  • “Drop box” schemes use a private mailbox facility as the fraudulent health care entity’s address, with the entity’s “suite” number actually being its mailbox number. The fraudulent entity then uses the address to submit fraudulent insurance claims and to receive insurance checks. For example, while the insurer sends payments to “Suite 478” at a certain address, payments are actually going to “Box 478” at a privately owned mailbox facility. The perpetrator then retrieves the checks and deposits them into a commercial bank account..
  • Third-party billing schemes revolve around a third-party biller—who may or may not be part of the scheme—who prepares and remits claims for health care providers. The third-party biller may add claims without the providers’ knowledge and keeping the remittances [11].

Bogus Health Insurance Companies

The GAO has issued two reports concerning the sale of health insurance plans that lack legal authorization. These plans place the buyer at risk for financial disaster if serious illness strikes. One report focuses on consumer vulnerability [12]. The other notes that from 2000 to 2002, 144 unauthorized entities enrolled at least 15,000 employers and more than 200,000 policyholders who got stuck for over $200 million in unpaid claims [13]. The investigatirs found that many of the entitles bore names similar to those of legitimate companies. In response to the report, the Health Insurance Institute of America is again urging the National Association of Insurance Commissioners to create an online database of licensed health insurance companies so that anyone can easily check the legitimacy of companies offering health insurance products. Meanwhile, the Coalition Against Insurance Fraud offers ten warning signs of a possible swindle:

  • The coverage costs 25 percent or more below the norm, yet promises generous benefits and a large provider network.
  • The plan readily accepts people with serious illnesses and other medical conditions that other plans normally reject.
  • The insurance has few or no underwriting guidelines—the agent or rep appears almost too eager to sign you up.
  • You’re approached by an insurance agent, phone or direct mail. Honest group plans normally are sponsored by your employer—and aren’t sold directly to individuals.
  • The plan isn’t licensed in your state, and the agent (falsely) assures you the federal ERISA law exempts the plan from state licensing.
  • The plan seems like insurance, but the agent or rep avoids calling “insurance,” and instead uses evasive terms such as “benefits.”
  • The agent or rep doesn’t have clear answers to your questions, seems ill-informed, or avoids sharing information.
  • You’ve never heard of that health insurance company—and nobody else has, either.
  • You have to join an “association” or “union” to obtain the health coverage. But you get no voting rights, receive no bylaws or other material, and aren’t involved in the group’s activities.
  • Your hospital keeps calling you to complain that your health plan isn’t paying your medical bills. Often the plan’s reps keep making flimsy excuses, or stop returning phone calls altogether [14].

Viatical Fraud

In a viatical settlement transactions, people with terminal illnesses assign their life insurance policies to viatical settlement companies in exchange for a percentage of the policy’s face value [15]. The company, in turn, may sell the policy to a third-party investor. The company or the investor then becomes the beneficiary to the policy, pays the premiums, and collects the face value of the policy after the original policyholder dies. Fraud occurs when agents recruit terminally ill people to apply for multiple policies. They misrepresent the truth and answer “no” to all of the medical questions. Healthy impostors then undergo the medical evaluation. In many cases, the insurance agent who issues the policy is a party to the scheme. The agent or one applicant may even submit the same application to many insurance companies. Viatical settlement companies then purchase the policies and sell them to unsuspecting third-party investors. The insurance industry is the biggest victim of this fraud [16]. Some investors receive nothing in return for their “guaranteed” investment.

Anti-Fraud Programs

Several large insurance companies have joined forces through the National Health Care Anti-Fraud Association to develop sophisticated computer systems to detect suspicious billing patterns. The Federal Bureau of Investigation (FBI) and the Office of the Inspector General (OIG) each have assigned hundreds of special agents to health-fraud projects. The Coalition Against Insurance Fraud, a public advocacy and educational organization founded in 1993, includes consumers as well as government agencies and insurers.
The Omnibus Consolidated Appropriation Act of 1997 authorized a Health Care Anti-Fraud, Waste, and Abuse Community Volunteer Demonstration Program to further reduce fraud and abuse in the Medicare and Medicaid programs. The program enrolled thousands of retired accountants, health professionals, investigators, teachers, and other community volunteers to help Medicare beneficiaries and others to detect and report fraud, waste, and abuse. The Health Insurance Portability and Accountability Act of 1996 funded a similar program that trained community agency workers [17]. This act also gave the U.S. Inspector General jurisdiction over private insurance plans as well as public ones.
The Inspector General’s office has recovered over a billion dollars through fines and settlements. Its Operation Restore Trust, which began in 1995, was a joint federal-state program aimed at fraud, waste, and abuse in three high-growth areas of Medicare and Medicaid: home health agencies, nursing homes, and durable medical equipment suppliers. The questionable activities included:

  • Billing for advanced life support services when basic life support was provided. Documentation may be falsified to indicate a patient needed oxygen—which is a key indicator in establishing medical necessity for advanced life support.
  • Billing for larger amounts of drugs than are dispensed; or billing for brand-name drugs when less expensive generic versions are dispensed.
  • Billing for more miles than traveled for transportation.
  • Falsification of documentation to substantiate the need for a transport from a hospital back to the patient’s home. Medicare will only cover transport from hospital to home if the patient could not go by any other means.

Allstate Insurance Company announced that during 2004, judges and juries around the country awarded the company more than $30 million in damages resulting from insurance fraud schemes against the company—the result of a campaign Allstate began in 2001 to go after the pocketbooks of fraud perpetrators in court. Since that time, the company has gotten more than $55 million in judgments against criminals that range from individuals to sophisticated organized crime syndicates. Unfortunately, bankruptcies and money laundering make it difficult to collect such awards. In February 2005, Allstate reported that only $5.24 million out of the $30.81 million awarded in 2004 had been recovered [18].

What You Can Do

Many frauds can be detected by examining insurance payment reports to see whether they accurately reflect the services rendered. Suspicious reports involving a private insurer claim should be reported to the company’s fraud department. Suspicious practices involving Medicare or other federal programs should be reported to the OIG Hotline by phone (1-800-368-5779) or e-mail.

Recommended Publications

Other Information Sources

References

  1. Department of Justice Health Care Fraud Report, Fiscal Year 1998. Washington, DC: Department of Justice, 1999.
  2. BlueCross & BlueShield United of Wisconsin. What is health care fraud? Accessed Nov 30, 1999.
  3. Guidelines to health care fraud. Adopted by the National Health Care Anti-Fraud Association Board of Governors, Nov 19, 1991.
  4. 1997 Documentation guidelines for evaluation and management services , Centers for Medicare & Medicaid Services, 1997.
  5. Rental of space in physician offices by persons or entities to which physicians refer. OIG Special Fraud Alert, February 2000.
  6. Homola S. Inside Chiropractic: A Patient’s Guide. Amherst, NY: Prometheus Books, 1999.
  7. Campbell WW and others. Recommended policy for electrodiagnostic medicine. American Association of Electrodiagnostic Medicine, Sept 26, 1996.
  8. Brown JG. Utilization parameters for chiropractic treatments. Washington, DC: Office of the Inspector General, Nov 1999.
  9. Stern RA, Montana R. Identify patterns of medical provider fraud through data base graphic pattern. FDN Fraud Report, Nov 1999.
  10. Barrett S. Chelation therapy and insurance fraud. Quackwatch, May 8, 2000.
  11. Hast RH. Health care fraud: Schemes to defraud Medicare, Medicaid, and private health care insurers. Testimony before the Subcommittee on Government Management, Information and Technology, Committee on Government Reform, House of Representatives. GAO/T-OSI-00-15, July 25, 2000.
  12. Private health insurance: Employers and individuals are vulnerable to unauthorized or bogus entities selling coverage. #GAO-04-312, Feb 2004
  13. Private health insurance: Unauthorized or bogus entities have exploited employers and individuals seeking affordable coverage. #GAO-04-512T, March 3, 2004.
  14. Scam alert. Coalition Against Insurance Fraud Web site, accessed March 5, 2004.
  15. Viatical settlements. FTC, 1998.
  16. Kohtz DA. Viatical fraud. Quackwatch, Aug 16, 2000.
  17. Implementation of the Administration on Aging’s health care fraud and abuse programs: 18-month outcomes. Washington, DC: Office of Evaluations and Inspections, Aug 1999.
  18. Fraudsters ordered to pay allstate more than $30 million in ’04. Allstate news release, Feb 14, 2005.
This article was revised on January 10, 2006.

Nine Rules and Procedures to Prevent Insurance Fraud

Nine Rules and Procedures to Prevent Insurance Fraud
(For the patient to know how your doctor, especially Dean K Ziegler of Ziegler Chiropractic, should be handling their billing practices.  Be on the look out…….)
By Michael J. Schroeder, Esq. and David S. Singer
Dynamic Chiropractic – October 24, 1990, Vol. 08, Issue 22

A doctor decides to help his cash patients by doing physical therapy at no charge. A doctor decides to give a new patient without insurance a reduced fee for an examination. A doctor decides to forgive the deductible and/or reduce the co-payments for certain patients.

A doctor has a patient who initially hurt himself at home but aggravated it at work; the doctor bills this through Workers’ Compensation. 

Any of the above examples could constitute insurance fraud. 
There is a nationwide attempt to reduce health care costs. Some of the more common techniques employed by the insurance industry are: 
  1. Sending investigators acting as patients
  2. Creating computer profiles of average office visit fees and average case costs, and then identifying doctors who significantly exceed these averages
  3. Pressing civil and criminal charges against doctors who engage in abusive practices
  4. Publicizing civil and criminal charges of insurance fraud
  5. Pursuing the enactment of new laws reducing chiropractic coverage
  6. Forcing doctors to compromise personal injury liens 

To Prevent This from Happening to You, Follow These Rules: 

Rule 1: Create Patient Protocol Based on Diagnosis Or Extent of Injury — Not Cash Versus Insurance Patients.
Despite how this might upset some doctors philosophically, the moment a doctor agrees to accept income from insurance, he has entered into a system based on the medical model of health care. Diagnosis and the degree of injury alone should determine the type of care and number of visits. Thus, the following example would not be legal: 
A person with a flexion/extension injury as the result of an auto accident comes to the doctor with insurance coverage. The doctor takes six x-rays and does a comprehensive examination charged at $85. The same doctor sees another patient who hit his head in the pool. This patient also has a flexion/extension injury but has no insurance. The doctor takes only two x-rays and does a brief examination for $25. 
The problem with this approach is two-fold. First, the doctor has represented that his fee for a flexion/extension injury examination is $85. If this is the “customary charge,” then the doctor should charge the same fee and perform the same service for the cash patient. When a doctor accepts a lower fee from a cash patient for a similar service as that given an insurance patient at a higher fee, that is two-tier billing and that is illegal. 
If the doctor wishes to offer a service such as a comprehensive examination to a cash patient and the patient wishes to decline that service, the doctor must make careful note of this in his records. A patient has the right to decline any treatment or diagnostic service. What is important is that the doctor offers the same service regardless of insurance. 
The second problem is the difference in the diagnostic approach between the two patients in regard to x-rays. The above example would imply the doctor treated the patient’s insurance policy rather than the patient. Malpractice exposure is also created if a doctor takes only two x-rays on a flexion/extension injury when his normal procedure would be to take five. Once again, the doctor should have recommended five views and given the patient an option to refuse. If the patient refused, this would need careful notation in the patient’s records. 
Rule 2: If a Patient Is in Financial Need, Have Him Put This in Writing Before Offering a Discounted Fee.
If a patient tells you that he truly cannot afford to receive care, you may wish to treat this patient at a reduced fee. If this is done without the patient putting something in writing, the variation in fees could be questioned long after the patient has gone or moved. A doctor’s statement that he was just helping a patient does not avoid the charge of insurance fraud. 
Additionally, many doctors mistake the ability to offer a reduced fee to the truly needy as authorization to classify all of their cash patients as “needy.” When a doctor offers discounts to substantially all of his cash patients based on “need,” the same discount must be given to insurance patients. 
Rule 3: Have Patients Sign in For Each Visit and Keep These Records For at Least Seven Years.
A disgruntled patient may claim that the doctor billed him for treatment that never occurred. The only proof the doctor has is his records. A patient’s own signature showing he was in the office is the best proof. This will also help the doctor to defend himself in a malpractice action. In fact, if the doctor is treating children, these records must be maintained for seven years after the child becomes an adult. 
Rule 4: If You Find You Have Made An Error in Billing, Notify the Insurance Carrier.
A doctor discovers his new insurance staff has billed all patients as having had therapy each visit when they did not. The staff did this in error. The doctor should correct his staff’s mistakes and immediately notify the insurance company of the error and its cause. Not only will this make it unlikely that the insurance company will take any further action against him, but it also undercuts the ability of the insurance company to accuse the doctor of fraud. Intent to defraud is a required element of any fraud claim, so if the doctor voluntarily alerts the insurance company of a mistake made, it looks much more like what it was — an innocent mistake. 
Rule 5: If You Receive Overpayment, Return It.
A doctor receives two payments for the same service from one insurance carrier, or receives two payments from two carriers for the same service. The doctor must return one of the checks to the insurance company. The only exception would be if the patient carried two private pay insurances that allowed double billing; then one payment goes to the patient. 
Rule 6: Family Plans Are Illegal Unless the Same Procedure Is Afforded to Both Insured and Cash Patients.
If a doctor gives cash patients one fee for the first patient and a lower fee for the other family members, then that doctor would have to give another family who were all in an auto accident the same low fee. As discussed previously, two-tiered billing is not legal. A safe family plan would be all children under the age of ten are seen once per month at no charge. Thus cash or insured children are not charged when they come but once per month. 
Rule 7: Maintenance Care Cannot Be a Lower Fee Unless Given to Insurance Patients on the Same Frequency.
As discussed above, two-tiered billing is simply not legal whether it is justified on cash/insurance grounds or on maintenance/treatment grounds. Once again, special hardships are permissible. However, if all cash patients appear to be under hardship, the spirit of the law has been violated and the doctor’s customary fee could be interpreted as the lower fee. Thus all higher billings to the insurance company could be construed as overbilling. 
Rule 8: Advertising No-Out-Of-Pocket Expense (Insurance Accepted As Full Payment) Is Illegal in Various States.
In many states, the insurance companies take the approach that if your normal fee is only 80% of what you bill, they will pay only against 80%. Thus, they pay 80% of 80%, i.e., 64%. In some states, the chiropractic boards are now requiring their licentiates to disclose to the insurance company each time a deductible or co-payment is forgiven. 
Rule 9: Working with a Medical Doctor May Violate State and Federal Laws.
A chiropractic doctor and a medical doctor can work together; however, proper legal planning is essential. A chiropractor cannot accept any form of kickback for a referral to such an MD In the case of Medicare, this could be considered Mail Fraud. Anyone wishing to create an integrated chiropractic and medical facility should get sound legal advice in writing before proceeding. 
In conclusion, a doctor must know the rules of the game. Failure to know the law does not exempt you from it. There is a legal way to accomplish your desire to serve and help people. Be sure to balance you desire to help with proper legal procedures. 
We wish you success and a trouble-free practice, and hope that these rules will serve as a good guideline.

Michael Schroeder has formed more than 300 chiropractic-medical practices since 1982. He is the current vice president and general counsel for the American Acupuncture Council, and for the last twelve years has been the vice president of the National Association of Chiropractic Attorneys (NACA). In 1995, NACA honored Mr. Schroeder as their “Attorney of the Year.”

Allentown chiropractor headed to jail for fraud, assault

January 26, 2012|By Kevin Amerman, Of The Morning Call

An Allentown chiropractor will spend up to 23 months in jail for billing insurance companies for work he didn’t do and, in a separate case, attacking his girlfriend at his office-home.

Dean K. Ziegler, 49, was sentenced Thursday to five to 23 months in Lehigh County Prison by Judge Maria L. Dantos.
Ziegler must report to the prison Friday morning to begin serving his sentence.
Ziegler pleaded guilty last month to insurance fraud, a felony, and simple assault, a misdemeanor.
Ziegler, who has run a business out of his residence at 101 S. 14th St., was charged with insurance fraud in December 2010. He allegedly billed five insurance companies for more than $3,300 worth of exams in January and February 2009 — while he was in Lehigh County Prison for violating parole in an unrelated case.
Acting on a tip, authorities said they investigated and determined Ziegler had billed the insurance companies for 10 appointments that never took place. He also allegedly submitted reimbursements for 12 manual therapy treatments, which cost more than the therapy that had actually been done, investigators said.
He was charged with assaulting his girlfriend at his home/office in September. Police said he punched 34-year-old Jill Aleene Bartholf, broke her nose with a kick and threw her down a flight of steps.
According to police:
When officers arrived at 3:40 a.m. Sept. 20, they found blood in front of the house, blood on the first and second floors and Bartholf sitting on a couch, bruised and bleeding from her nose.
Ziegler fled in his car before officers showed up and was arrested later. Bartholf was taken by ambulance to a hospital.

Harassment update….

It appears that the case of Dean K Ziegler (Affiant) vs John Blum is going to be continued for another date.  The affiant has requested a continuance and the judge will probably grant it.  So that means 1. my blog will continue and 2. I have more time to prepare.

To summarize….   I have (based on first amendment rights) reviewed Dean K Ziegler and Ziegler Chiropractic.  I have provided my experiences with the same in hopes that others are not being taken advantage of by the affiants actions.

Those actions include the following.

Dean K Ziegler has been charged with fraud and other criminal charges.  I have taken the stand to report on those charges in hopes that others are not taken advantage of by Mr. Dean K Ziegler.

You have many choices when it comes to chiropractor in the Allentown Area… CHOOSE WISELY!!!

Be Wary of "No Out-of-Pocket Expense" Offers

This is something Dean K Ziegler of Ziegler Chiropractic did for me and others.  I didn’t realize how bad it was:  Taken from http://www.chirobase.org/19Insurance/noope.html


It is illegal to routinely excuse patients from insurance copayments and deductibles. (A copayment is a fixed dollar amount paid whenever an insured person receives specified health-care services. A deductible is the amount that must be paid before the insurance company starts paying.) It is legal to waive a fee for people with a genuine financial hardship, but it is not legal to provide completely free care or discounts to all patients or to collect only from those who have insurance. Studies have shown that if patients are required to pay for even a small portion of their care, they will be better consumers and select items or services because they are medically needed rather than because they are free. Routine waivers thus raise overall health costs. They are considered fraudulent because averaging them with the doctor’s full fees would make the “usual” fees lower than the amounts actually billed for.
The document below pertains to Medicare providers, but the same principles apply to all insurance plans with copayments or deductibles. In Kennedy v. Connecticut General Life Insurance Co., 924F2nd (1991), a U.S. Court of Appeals held that by waiving the deductible and copayment, a chiropractor relieved both the insurance company and the patient of any obligation to pay for the chiropractor’s services. The court reasoned that because the insurance plan required co-payments to help hold down the cost of care, the chiropractor could not waive them without violating his contract with the company. And because the chiropractor had contracted with the patient to accept whatever the insurance company paid on the patient’s behalf. the patient had no obligation either.


DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of Inspector General Special Fraud Alert:
Routine Waiver of Copayments or Deductibles Under Medicare Part B

May 1991

To help reduce fraud in the Medicare program, the Office of Inspector General is actively investigating health care providers, practitioners and suppliers of health care items and services who (1) are paid on the basis of charges and (2) routinely waive (do not bill) Medicare deductible and copayment charges to beneficiaries for items and services covered by the Medicare program.
[Footnote:] This fraud alert is not intended to address the routine waiver of copayments and deductibles by providers, practitioners or suppliers who are paid on the basis of costs or diagnostic related groups. The fact that these types of services are not discussed in this fraud alert should not be interpreted to legitimize routine waiver of deductibles and copayments with respect to these payment methods. Also, it does not apply to a waiver of any copayment by a Federally qualified health care center with respect to an individual who qualifies for subsidized services under a provision of the Public Health Service Act.

What Are Medicare Deductible and Copayment Charges?

The Medicare “deductible” is the amount that must be paid by a Medicare beneficiary before Medicare will pay for any items or services for that individual. Currently, the Medicare Part B deductible is $100 per year.
“Copayment” (“coinsurance”) is the portion of the cost of an item or service which the Medicare beneficiary must pay. Currently, the Medicare Part B coinsurance is generally 20 percent of the reasonable charge for the item or service. Typically, if the Medicare reasonable charge for a Part B item or service is $100, the Medicare beneficiary (who has met his [or her] deductible) must pay $20 of the physician’s bill, and Medicare will pay $80.

Why Is it Illegal for “Charged-Based” Providers, Practitioners and
Suppliers to Routinely Waive Medicare Copayment and Deductibles?

Routine waiver of deductibles and copayments by charge-based providers, practitioners or suppliers is unlawful because it results in (1) false claims, (2) violations of the anti-kickback statute, and (3) excessive utilization of items and services paid for by Medicare.
A “charge-based” provider, practitioner or supplier is one who is paid by Medicare on the basis of the “reasonable charge” for the item or service provided. 42 U.S.C. 1395u(b)(3); 42 CFR 405.501. Medicare typically pays 80 percent of the reasonable charge. 42 U.S.C. 1395l(a)(1). The criteria for determining what charges are reasonable are contained in regulations, and include an examination of (1) the actual charge for the item or service, (2) the customary charge for the item or service, (3) the prevailing charge in the same locality for similar items or services. The Medicare reasonable charge cannot exceed the actual charge for the item or service, and may generally not exceed the customary charge or the highest prevailing charge for the item or service. In some cases, the provider, practitioner or supplier will be paid the lesser of his [or her] actual charge or an amount established by a fee schedule.
A provider, practitioner or supplier who routinely waives Medicare copayments or deductibles is misstating its actual charge. For example, if a supplier claims that its charge for a piece of equipment is $100, but routinely waives the copayment, the actual charge is $80. Medicare should be paying 80 percent of $80 (or $64), rather than 80 percent of $100 (or $80). As a result of the supplier’s misrepresentation, the Medicare program is paying $16 more than it should for this item.
In certain cases, a provider, practitioner or supplier who routinely waives Medicare copayments or deductibles also could be held liable under the Medicare and Medicaid anti-kickback statute. 42 U.S.C. 1320a-7b(b). The statute makes it illegal to offer, pay, solicit or receive anything of value as an inducement to generate business payable by Medicare or Medicaid. When providers, practitioners or suppliers forgive financial obligations for reasons other than genuine financial hardship of the particular patient, they may be unlawfully inducing that patient to purchase items or services from them.
At first glance, it may appear that routine waiver of copayments and deductibles helps Medicare beneficiaries. By waiving Medicare copayments and deductibles, the provider of services may claim that the beneficiary incurs no costs. In fact, this is not true. Studies have shown that if patients are required to pay even a small portion of their care, they will be better health care consumers, and select items or services because they are medically needed, rather than simply because they are free. Ultimately, if Medicare pays more for an item or service than it should, or if it pays for unnecessary items or services, there are less Medicare funds available to pay for truly needed services.
One important exception to the prohibition against waiving copayments and deductibles is that providers, practitioners or suppliers may forgive the copayment in consideration of a particular patient’s financial hardship. This hardship exception, however, must not be used routinely; it should be used occasionally to address the special financial needs of a particular patient. Except in such special cases, a good faith effort to collect deductibles and copayments must be made. Otherwise, claims submitted to Medicare mat violate the statutes discussed above and other provisions of the law.

What Penalties Can Someone Be Subject to for Routinely Waiving Medicare Copayments or Deductibles?

Whoever submits a false claim to the Medicare program (for example, a claim misrepresents an actual charge) may be subject to criminal, civil or administrative liability for making false statements and/or submitting false claims to the Government. 18 U.S.C. 287 and 1001; 31 U.S.C. 3729; 42 CFR 1320a-7a). Penalties can include imprisonment, criminal fines, civil damages and forfeitures, civil monetary penalties and exclusion from Medicare and the State health care programs.
In addition, anyone who routinely waives copayments or deductibles can be criminally prosecuted under 42 U.S.C. 1320a-7b(b), and excluded from participating in Medicare and the State health care programs under the anti-kickback statute. 42 U.S.C. 1320a-7(b)(7).
Finally, anyone who furnishes items or services to patient substantially in excess of the needs of such patients can be excluded from Medicare and the State health care programs. 42 U.S.C. 1320a- 7(b)(6)(B).

Indications of Improper Waiver of Deductibles and Copayments

To help you identify charge-based providers, practitioners or suppliers who routinely waive Medicare deductibles and copayments, listed below are some suspect marketing practices. Please note that this list is not intended to be exhaustive but, rather, to highlight some indicators of potentially unlawful activity.

  • Advertisements which state: “Medicare Accepted As Payment in Full,” “Insurance Accepted As Payment in Full,” or “No Out-Of- Pocket Expense.”
  • Advertisements which promise that “discounts” will be given to Medicare beneficiaries.
  • Routine use of “Financial hardship” forms which state that the beneficiary is unable to pay the coinsurance/deductible (i.e., there is no good faith attempt to determine the beneficiary’s actual financial condition).
  • Collection of copayments and deductibles only where the beneficiary has Medicare supplemental insurance (“Medigap”) coverage (i.e., the items or services are “free” to the beneficiary).
  • Charges to Medicare beneficiaries which are higher than those made to other persons for similar services and items (the higher charges offset the waiver of coinsurance.)
  • Failure to collect copayments or deductibles for a specific group of Medicare patients for reasons unrelated to indigency (e.g., a supplier waives coinsurance or deductible for all patients from a particular hospital, in order to get referrals).
  • “Insurance programs” which cover copayments or deductibles only for items or services provided by the entity offering the insurance. The “insurance premium” paid by the beneficiary is insignificant and can be as low as $1 a month or even $1 a year. These premiums are not based upon actuarial risks, but instead are a sham used to disguise the routine waiver of copayments and deductibles.

If you have information about health care providers, practitioners, entities or other persons engaging in these types of activities or arrangements described above, contact any of the regional offices of the Office of Investigations of the Office of Inspector General, U.S. Department of Health and Human Services,

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This article was posted on March 15, 2004.

When someone provides false information to an insurance company in order to gain something of value that he or she would not have received if the truth had been told‚ they’ve committed insurance fraud.

CLICK HERE TO GO TO THE SITE  taken from the PA Insurance Fraud Prevention Authority 

Health Insurance Fraud

In this type of fraud‚ false or misleading information is provided to a health insurance company in an attempt to have them pay unauthorized benefits to the policy holder‚ another party‚ or the entity providing services. The offense can be committed by the insured individual or the provider of health services.

An individual subscriber can commit health insurance fraud by:
  • allowing someone else to use his or her identity and insurance information to obtain health care services
  • using benefits to pay for prescriptions that were not prescribed by his or 
    her doctor
Health care providers can commit fraudulent acts by:
  • billing for services‚ procedures and/or supplies that were never rendered
  • charging for more expensive services than those actually provided
  • performing unnecessary services for the purpose of financial gain
  • misrepresenting non–covered treatments as a medical necessity
  • falsifying a patient’s diagnosis to justify tests‚ surgeries‚ or other procedures
  • billing each step of a single procedure as if it were a separate procedure
  • charging a patient more than the co–pay agreed to under the insurer’s terms
  • paying “kickbacks” for referral of motor vehicle accident victims for treatment 

Examples

Here are a few typical scenarios to illustrate some of the different ways health insurance fraud can be committed:

Chris was the only one in his family with health insurance, but he let his brother and cousin use his card to receive health care benefits.

A nurse in Dr. Smith’s office became addicted to painkillers and with access to patient records she called in forged prescriptions to a local pharmacist and posed as a family member of the patient when she picked up the drugs.

Devon was addicted to painkillers, stole and forged prescription forms from his doctor’s office, passed them at a local pharmacy, and used his health care insurance to pay for the drugs.

Dr. Talbot billed his patients’ health insurance for both the services he actually provided and for services that were not provided. He falsified his patients’ medical records to reflect office visits and treatments that never occurred.

Dr. O’Neill received the results of medical testing performed by a diagnostic firm for her interpretation of the results. She billed the patients’ health insurance as though she performed both the testing and interpretation of the tests. 

Dr. Salazar was employed by a medical center where low-income and indigent patients were recruited to undergo unnecessary exams. While Dr. Salazar saw few patients, medical records were falsified by a physician’s assistant to support the billing of insurance programs for procedures that were never performed.

Consequences

Most health insurance includes specific benefits‚ and health insurance fraud practices such as overbilling for the type of services received robs consumers of these benefits.
This is why health insurance fraud is such a serious crime. As with all other types of insurance fraud‚ Pennsylvania considers it a felony. Violators can spend up to seven years in prison and spend up to $15‚000 in fines. There are also many other associated expenses such as court costs and legal fees. Plus‚ those found guilty of insurance fraud have the stigmas and limitations of being a convicted felon to carry with them for life.

Chirobase: Your Skeptical Guide to Chiropractic History, Theories, and Practices

A great online resource.  Just click:

Chirobase: Your Skeptical Guide to Chiropractic History, Theories, and Practices

Accurate information about chiropractic is not easy to get. Most publishers, editors, and broadcasters are unwilling to examine this topic in depth and to publish critical information. As a result, most reports reaching the public express what chiropractors would like people to believe. This Web site will enable you to deepen your understanding. If you decide to seek chiropractic care, it may also help you find a suitable practitioner. – See more at: http://www.chirobase.org/index.html#sthash.2mQcfj0e.dpuf